- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $224.97 / $224.97 / $1,146.95
| Professional | | $224.97 | $224.97 | $1,146.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $830.92 / $1,055.08 / $1,227.18
| Facility | | $830.92 | $1,055.08 | $1,227.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $305.57 / $487.16 / $487.16
| Professional | | $305.57 | $487.16 | $487.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,788.12 / $2,068.85 / $3,173.73
| Professional | | $1,788.12 | $2,068.85 | $3,173.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $224.97 / $224.97 / $683.39
| Professional | | $224.97 | $224.97 | $683.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.99 / $1,632.77 / $2,120.82
| Professional | | $1,122.99 | $1,632.77 | $2,120.82 |